USMLE Forum Archives - USMLE Step 3 - MHR: Sinusitis
MHR: Sinusitis
meduploader - 05-06-09 10:04
Sinusitis :
Headache ( worse on leaning forward),facial pain, nasal discharge.
Criteria for diagnosis:
Maxillary toothache
Purulent nasal secretion
History of colored Nasal discharge
Poor response to nasal Decongestants
Abnormal Sinus Transillumination
If 4 or more criteria + diagnosis is definite
If 2 or 3 criteria + Diagnosis is intermediate recommended initial study Sinus CT
If less than 2 criteria negative for sinusitis
Most common is maxillary sinusitis. Next common is Frontal. Ethmoids are most commonly affected in children. Sphenoid has highest risk of intracranial spread
Symptoms may last as long as 4 weeks in acute sinusitis, Symptoms b/w 4-8 weeks is subacute and symptoms persisting > 8 weeks is chronic sinusitis.
In recurrent sinusitis, there are 3 or more episodes of acute sinusitis per year, and different episodes may be caused by different organisms.
Symptoms suggesting bacterial etiology
Symptoms persist beyond 10 to 14 days, Remember that under 10 days, viral sinusitis predominates, By day 10, 40% of sinusitis resolves spontaneously 0.5% of viral URIs develop into bacterial sinusitis
Symptoms worsen after 5-7 days ( double sickening)
purulent nasal discharge
Unilateral maxillary sinus tenderness
Maxillary tooth or facial pain (esp. if unilateral)
Its a clinical Dx, so if asked best next step in management Rx
DX: Maxillary sinus x-ray ( best initial test )
Most accurate sinus aspirate for culture. This is more accurate than a CT (you cant culture a radiologic test)
Dx in children
meduploader - 05-06-09 10:04
Sinusitis :
Headache ( worse on leaning forward),facial pain, nasal discharge.
Criteria for diagnosis:
Maxillary toothache
Purulent nasal secretion
History of colored Nasal discharge
Poor response to nasal Decongestants
Abnormal Sinus Transillumination
If 4 or more criteria + diagnosis is definite
If 2 or 3 criteria + Diagnosis is intermediate recommended initial study Sinus CT
If less than 2 criteria negative for sinusitis
Most common is maxillary sinusitis. Next common is Frontal. Ethmoids are most commonly affected in children. Sphenoid has highest risk of intracranial spread
Symptoms may last as long as 4 weeks in acute sinusitis, Symptoms b/w 4-8 weeks is subacute and symptoms persisting > 8 weeks is chronic sinusitis.
In recurrent sinusitis, there are 3 or more episodes of acute sinusitis per year, and different episodes may be caused by different organisms.
Symptoms suggesting bacterial etiology
Symptoms persist beyond 10 to 14 days, Remember that under 10 days, viral sinusitis predominates, By day 10, 40% of sinusitis resolves spontaneously 0.5% of viral URIs develop into bacterial sinusitis
Symptoms worsen after 5-7 days ( double sickening)
purulent nasal discharge
Unilateral maxillary sinus tenderness
Maxillary tooth or facial pain (esp. if unilateral)
Its a clinical Dx, so if asked best next step in management Rx
DX: Maxillary sinus x-ray ( best initial test )
Most accurate sinus aspirate for culture. This is more accurate than a CT (you cant culture a radiologic test)
Dx in children
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#1
Re: MHR: Sinusitis
meduploader - 05-06-09 10:06 Dx in children less than 6 is based on clinical rather than radiological criteria.
RX:Uncomplicated decongestant , Analgesic
Complicated (discolored nasal discharge) Antibiotics
ANTIBIOTICS:
Indicated only in acute bacterial Sinusitis
Protocol àAntibiotic course à Minimum course: 10-14 days àLonger course for persistent symptoms: 28 days
Change antibiotic if no improvement in 3 days REMEMBER THAT Beta-lactamase resistance in acute cases:
#2
Re: MHR: Sinusitis meduploader - 05-06-09 10:07 : less than 30% , Beta-lactamase resistance in chronic cases: 40-50%
First-Line à Indications to start on first-line agents àMild to moderate symptoms , No daycare exposure & No recent antibiotic use
Amoxicillin à Disadvantages: Misses Beta-lactamase producers : Haemophilus Influenzae , Moraxella catarrhalis & Penicillin Resistant Pneumococcus (increasing)
Trimethoprim Sulfamethoxazole (Bactrim) No longer recommended as first-line agent , Higher resistance rate than other agents
à Disadvantages : Misses Staphylococcus , Risk of Toxic Epidermal Necrolysis & Risk of Steven's Johnson Syndrome
Second-Line à Indications to start on second-line agents : Severe symptoms, Daycare exposure , Recent antibiotic use.
Amoxicillin-Clavulanate (Augmentin ) or Cefuroxime (Zinacef) , Cefpodoxime
Avoid Cefixime ( poor Gram + coverage )
Third Line recommendation àIf no improvement with above a) Consider adding Flagyl to second-line agents b) Consider second-line agent for longer course (4 week) c) Switch to Fluoroquinolone (avoid under 16 yrs of age ), Moxifloxacin or Gatifloxacin (Tequin)
Management : Penicillin or Cephalosporin Allergy
à Macrolide antibiotics (High bacterial resistance rate) à Erythromycin , Azithromycin (Zithromax) or Clarithromycin (Biaxin)
Trimethoprim-Sulfamethoxazole (Bactrim) à Increasing bacterial resistance, So other agents are preferred for Sinusitis
Clindamycin à Consider in combination with Rifampin if severe , Poor efficacy against Gram Negative Bacteria
Fluoroquinolones ( avoid under age 16 years )
“Unless severe symptoms of acute sinusitis develop, such as fever, facial pain or tenderness, or periorbital swelling, antibiotics should be withheld for 10 to 14 days. Although the primary therapy for acute bacterial sinusitis is antibiotics, increasing resistance to penicillin may necessitate the use of alternative antibiotics. The choice of antibiotics is based on predicted efficacy, cost, and adverse effects. A 10- to 14-day course is generally adequate for acute disease, but shorter courses may be indicated for newer antibiotics. If there is no improvement in 3 to 5 days, an alternative antibiotic should be considered” ( guidelines, journal of clinical immunology, 2006)
Primary therapy for acute bacterial sinusitis is antibiotics with a 10- to 14-day course considered adequate. Amoxicillin is a drug of choice with trimethoprim-sulfamethoxazole an alternative.
If no response occurs within 3 to 5 days, a change to high-dose amoxicillin-clavulanate, cephalosporins, or macrolides may be indicated.
In areas of high antibiotic resistance or with failure to improve after 21 to 28 days, broad spectrum single agents should be considered, such as amoxicillin-clavulanate, cefuroxime, or cefpodoxime, or use of anaerobic coverage, such as clindamycin or metronidazole.
Nasal corticosteroids are indicated in acute and chronic sinusitis and short-term adjunct oral steroids may be used after failure of response or when nasal polyps are present.
Saline nasal sprays may help to reduce crusting!!
Acute Sinusitis – Complications
Unless severe symptoms of acute sinusitis develop, such as fever, facial pain or tenderness, or periorbital swelling, antibiotics should be withheld for 10 to 14 days.
Complications : Orbital Cellulitis, Meningitis, Extradural abscess , Subdural abscess , Brain abscess , Osteomyelitis and Cavernous Sinus Thrombosis. Do a CT to Dx or rule out complicax.
Symptoms: Red Flag (consider immediate ENT referral)
à High Fever over 102.2 F (39 C) or peristent fever
à Visual complaints (e.g. Diplopia)
à Periorbital edema or erythema ( check for EOMs à ?pain)
à Mental status changes
à Severe facial or dental pain
à Infraorbital hypesthesia
à consider referral in immunodeficiency or if persistent symptoms despite treatment
#3
Re: MHR: Sinusitis harry206 - 05-06-09 10:07 hmm now this look very modified to me :)
Good......waiting for full ID :)
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